1 Chapter 103: Benign Mucosal and Saccular Disorders

Chapter 103: Benign Mucosal and Saccular Disorders; Benign Laryngeal Tumors Robert W. Bastian Benign vocal fold mucosal disorders such as vocal nodules, laryngeal polyps, mucosal hemorrhage, intracordal cysts, mucosal bridges, and glottic sulci seem to be caused primarily by vibratory trauma (excessive vopice use). In my experience, an expressive, talkative personality correlates most consistently with the occurrence of most of these entities. (Some believe that epidermoid cysts and sulci have a congenital origin, but I have seen these entities so far only in persons who use or have used their voices extensively.) Occupational and life- style vocal demands come in a distant second, unless those demands are extraordinary. Cigarette smoke is clearly a cofactor along with unrestricted voice use in the formation of smoker's polyps. Other secondary influences such as infection, allergy, and acid reflux may also increase the mucosa's vulnerability to the kinds of injury that may occur during mucosal oscillation. Nonsingers with benign vocal fold mucosal disorders present for evaluation because of a change in the sound of the speaking voice. On the other hand, singers with normal sounding speaking voices may seek professional evaluation because of singing voice (usually upper range) limitations. The significance of the benign vocal fold mucosal disorders derives from the voice's importance for spoken and/or sung communication and occupation, along with its contribution to identity. Benign vocal fold mucosal disorders are common. Statistics from my voice laboratory between 1983 and 1987 reveal that more than half of all patients with voice complaints were found to have a benign mucosal disorder. Forty-five percent of 977 patients reported by Brodnitz (1963) had a diagnosis of nodules, polyps, or polypoid thickening. Also, slightly more than 50% of Kleinsasser's cancer-oriented experience with 2618 patients between 1964 and 1975 included patients with one of these benign entities (Kleinsasser, 1979). Anatomy and Physiology The anatomy most relevant to the benign vocal fold mucosal disorders is the "microarchitecture" of the vocal folds, as seen on whole-organ coronal sections in the study of cancer growth patterns (Cummings et al, 1984; Michaels, 1984) or in the work of Hirano (1981b). From medial to lateral the membranous vocal fold is made up of squamous epithelium, Reinke's potential space (superficial layer of the lamina propria), the vocal ligament (elastin and collagen fibers), and the thyroarytenoid muscle. Perichondrium and thyroid cartilage provide the lateral boundary of the vocal fold (Fig. 103-1). The mucosa (epithelium and Reinke's potential space) that covers the vocal folds is the chief oscillatory "moving part" during phonation, so that one can almost speak of "vocal fold mucosal vibration" rather than "vocal fold vibration". In a canine study that supports this idea, Saito et al (1981) placed metal pellets at varying depths into the canine vocal fold (epithelially, subepithelially, intramuscularly, and so on) and used x-ray stroboscopy to trace their coronal plane trajectories during vibration. Mucosal pellet trajectories were far wider 1 than those of the ligament or the muscle. If one can extrapolate to the human larynx, primarily the vocal fold mucosa oscillates to produce sound. Hirano's work (Ludlow and Hart, 1981) provides an explanation for Saito's observation. Hirano described the vocal fold muscle as the body of the fold, the epithelium and superficial layer of lamina propria (Reinke's potential space) as the cover, and the intermediate layers of collagenous and elastic tissue (vocal ligament) as the transitional zone (see Fig. 103-1). Because of the different stiffness characteristics of these layers, they are somewhat decoupled mechanically from each other during phonation, and the mucosa can therefore oscillate with a degree of freedom from the ligament and muscle, in a manner similar to the relative freedom from the paddle experienced by the red rubber ball and elastic band in a child's paddleball toy. During phonation, pulmonary air power supplied to adducted vocal folds is transduced into acoustic power as the vocal fold (mucosa) vibrates passively according to the length, tension, and edge configuration determined by the intrinsic muscles and elastic recoil forces of the laryngeal tissues. Fig. 103-2 provides the simplest overview of one vibratory cycle. Further details concerning vocal fold histology and vibratory behavior can be found in the references. Other important microanatomy includes glandular elements located in the supraglottic, saccular, and infraglottic areas. These glands produce secretions that bathe the vocal folds during vibration. Evaluation of Patient History A detailed questionnaire may help in taking a complete history (Bastian, 1988); however, a few basic but sometimes overlooked lines of inquiry provide a majority of the information crucial to the diagnostic process. Specifically, besides the usual items in the complete medical history, the voice history should probe deeply the onset and duration of vocal symptoms, known causes or exacerbating influences, nature and severity of symptoms, personality (particularly with respect to the issue of "talkativeness"), vocal commitments/activities, and vocal aspirations and consequent motivation for rehabilitation. With respect to the question of onset and duration, it is appropriate during history- taking to test the hypothesis that a patient who complains of frequently recurring bouts of vocal dysfunction may be experiencing exacerbations of a more chronic overuse disorder. Such a patient, who is often found to be living "at the edge" vocally based on assessment of personality, life-style, vocal commitments, and voice production, can be easily thrown over the edge by a small increase of vocal activity or an upper respiratory infection. The most helpful intervention for this kind of patient with focus not only on the patient's chief complaint for the visit (most recent exacerbating influence), but also (often with the help of a speech pathologist) on optimizing the patient's vocal hygiene, life-style and personality management, occupational use of voice, and efficiency of voice production. Concerning the cause of the disorder, it is also prudent to maintain a mild degree of skepticism initially when patients with nodules or polyps suspect that their difficulties resulted from allergies or "phlegm". In my experience, allergies in particular usually play a minor role 2 at most as compared to the behavioral causes of these mucosal injuries. Singers who have no speaking voice symptoms but who describe an exaggeration of day-to-day variability of singing capabilities, increased effort for singing, reduced vocal endurance, deterioration of high soft singing, and delayed phonatory onsets are usually found to have a mucosal disturbance. Singers in this circumstance whose screening laryngeal examination appears normal should be referred for laryngeal videostroboscopy, preferably by a physician skilled in the diagnosis and management of professional voice users. Because there appears to be such a strong relationship between personality and the formation/maintenance of many benign vocal fold mucosal disorders, the clinician should pay close attention to this issue. As one example of how to do this, I ask all patients to place themselves on a 7-point "talkativeness" scale, where 1 = very untalkative, 4 = average talkative, and 7 = unusually talkative. Virtually all patients with nodules and polyps, and even cysts and sulci, describe themselves at "6's" or "7's", with the possible exception of those individuals who work in vocally extreme occupations such as financial trading or full-time popular music or theater-based vocal performance. To gain an appreciation of vocal commitments/activities, the clinician can inquire not only about occupation, but also into the nature and extent of vocal activities related to family life and child care, politics, religion, athletics, vocal performance, and singing for personal pleasure. Inquiry into the patient's vocal aspirations and motivation is important in that the laryngologist's approach may differ markedly for the patient who only wants to be reassured that his or her hoarseness is not caused by cancer, as compared to the patient who must be relieved of limitations caused by mucosal swellings to pursue a competitive performing career. Auditory-perceptual assessment of vocal capabilities This often-neglected part of the evaluation provides the best means of understanding the nature and severity of the voice disturbance. Voice clinicians (preferably both the laryngologist and the speech pathologist) must model and elicit spoken and sung vocal tasks with their own voices (and a pitch reference such as a small electronic keyboard) and then analyze with auditory perception in order to assess basic vocal capabilities and limitations (for example, average/anchor speech frequency, maximum frequency and intensity ranges, ability to perform tasks that detect swelling (Bastian et al, 1990), register use, and perhaps a maximum phonation time). During this "vocal capability battery" the clinician also searches for inconsistencies between spoken and sung capabilities and takes note of the patient's level of effort and overal "vocal personality". Vocal capability testing requires only a few minutes to perform, in that the examiner is focusing primarily on the extremes of physical capability and only secondarily on

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